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Cervical infections

Section: Head and neck Curriculum: Curriculum, page 43

General

  • Deep space neck infections following the multiple fascial planes
  • Potentially airway and life threatening

Fascial Spaces

  • Summary
    • Retropharyngeal space (between buccopharyngeal fascia and alar fascia (anterior PVF)
      • Runs from skull to tracheal bifurcation (superior/post mediastinum)
        • Alar fascia (anterior leaf PVF)
    • Danger space (between ant alar and post PVF of PVF
      • Runs from skull to diaphragm
    • Prevertebral space between post PVF leaflet and VC
      • Can dissect along spinal column to coccyx
      • Continuous with psoas fascia

Submandibular and Sublingual Space

  • Borders
    • Anterior and lateral - mandible
    • Superior - mylohyoid
    • Inferior - hyoid bone
    • Medial - anterior belly of digastric
  • Sublingual space is superior to the submandibular space (above mylohyoid) but continuous with it posteriorly
  • Infection can cause
    • Tongue swelling and airway obstruction
    • Ludwig’s angina- potentially life threatening and rapidly spreading cellulitis originating from dental infection and causing infection of the floor of the mouth (all three spaces - submandibular, submental and sublingual)

Parapharyngeal Space

  • Inverted cone - base of skull to hyoid
  • Boundaries
    • Lateral
      • Superficial layer of deep cervical fascia extending between styloid process and mandibular ramus
      • Mandible
      • Muscles of mastication
    • Medial
      • Superior pharyngeal constrictor
    • Inferior
      • Hypoid
    • Superior
      • Skull base
  • Communicates with retropharyngeal space laterally at carotid sheath area
  • Divided into 2 compartments by styloid process + muscles, stylomandibular ligament and their attachment to hyoid bone
    • Anterior (muscular)
      • No important contents
      • Closely related to tonsillar fossa
    • Posterior (neurovascular)
      • CN 9 and 12 superiorly
      • CN 10 inferiorly
      • Carotid sheath and contents
        • Sheath runs in posterior aspect of parapharyngeal space
        • Pierces apex of cone to enter mediastinum
      • Sympathetic trunk
  • Infection - from pharyngitis, tonsillitis, parotitis, otitis or mastoiditis, odontogenic infection and masticator space infection

Retropharyngeal Space

  • Behind hypopharynx and oesophagus
  • Between pretracheal fascia anteriorly and alar fascia posteriorly
  • Anteriorly - buccopharyngeal fascia which surrounds the constrictor muscles
  • Posteriorly - alar fascia which is a delamination of the prevertabral fascia that attaches to the buccopharyngeal fascia at about C7
  • Communicates with parapharyngeal space laterally

Danger Space

  • (MOST important FOR INFECTION SPREAD FROM NECK TO CHEST)
  • Located behind the retropharyngeal space
  • Behind alar fascia and in front of the prevertebral fascia
  • From base of skull to diaphragm through POSTERIOR MEDIASTINUM

Prevertebral Space

  • Base of skull to coccyx and continuous with psoas fascia
  • Posterior to the danger space
  • Anterior = prevertebral fascia
  • Posterior = Vertebral column
  • Infection can dissect all the way down the spinal column

Other spaces

  • Pretracheal Space
  • Peritonsillar Space
  • Parotid Space

Lymph Nodes

  • Lateral cervical chain = common root for drainage
    • Large deep chain = all H+N final drainage
    • Along carotid sheath
    • When infected → enlarge → can cause bacteraemia
  • MALT - mucosa associated lymphoid tissue (like GALT)
    • Waldeyers ring
      • Nasopharyngeal lymphoid tissue aggregation
      • Palatine, lingual, adenoid and tonsillar lymphoid tissue
      • When inflamed can cause acute AW obstruction

Pathogenesis

  • Arise secondary to primary infections of
    • Mandibular teeth
    • Tonsils
    • Parotid
    • Deep cervical LN
    • Middle ear
    • Paranasal sinuses

Microbiology

  • Polymicrobial
    • Normal flora of upper respi tract and its all interconnected
  • Can vary based on location
    • Odontogenic
      • G+ - strep viridans, strep anginosus
      • Anaerobes - peptostrep, bacteroides, actinomyces
    • Oropharyngeal
      • Strep pyogenes, haemophilus, fusobacterium
    • Otogenic
      • Staph aureus, pseudomonas
    • Sinogenic
      • Strep pneumoniae, haemophilus, moraxella, staph aureus
    • Prevertebral
      • Staph aureus, pseudomonas, mycobacteria, fungi
    • Less common bugs in susceptible (imm comp, DM, trauma)
      • Pseudomonas
      • Enterobacter
      • Klebsiella pneumoniae

Clinical

  • Sepsis
  • Sore throat
  • Trismus - inability to open jaw
    • → pressure/infection on muscles of mastication (masseter/pterygoids) or
    • CN 5 motor branch
  • Dysphagia/odynophagia
  • Stridor/SOB
  • Dysphonia/hoarseness - CN10
  • Unilateral tongue paresis - CN12
  • External palpation not helpful but oral cavity palpation may be
  • Bulging pharyngeal wall (unilateral)
  • Torticollis
  • Stiff neck
  • Crepitus
  • Examination includes - full ENT exam

Investigations

  • If AW compromised → SORT AW FIRST
  • Bloods and cultures
  • CT head, neck and maybe chest with IV contrast
  • MRI
  • X-rays - thickened prevertebral soft tissues, air-fluid levels, FB, cervical lordosis, tracheolaryngeal forward displacement

Management

  • Concepts
  • Early ICU/anaesthetics/ENT involvement
  • AIRWAY
  • Assess and secure early

Medical

  • IV abx - maximum doses of broad coverage and narrow spectrum with culture results

Radiological

  • USS or CT drainage
  • Consider in the stable pt with no airway compromise and infection confined to the neck
  • Low threshold to proceed to operative management

Surgical

  • Considerations
    • Only do when there is evidence of pus/collection
    • Doing it too early can destroy the natural tissue planes and hasten the spread of infection
    • AIRWAY
  • Indications
    • Unstable patient
    • Airway compromise
    • Failed non-operative mx
  • Complications
    • Facilitating infection spread - disruption of natural tissue planes
    • Nerve injury - CN 5, 7, 9, 10, 11, 12
    • Vascular injury - carotid sheath
    • Haematoma
    • Tracheoesophageal injury and fistula How To Do

Incision and Drainage

  • Transoral I+D
  • Transcervical I+D

Cricothyroidotomy

Summary of Abscess Types

  • Parapharyngeal Space
    • Cause
      • Dental, peristonsillar abscess, parotitis, otitis, mastoiditis
    • Clinical
      • Trismus, swelling below angle of mandible, medial pharyngeal wall bulging, sepsis
      • Anterior compartment - std, posterior compartment - Horners or the like for CN 9, 10 and 12
    • Complications
      • Carotid sheath involvement (carotid mycotic aneurysm, IJV septic emboli), AW obstruction, sepsis
  • Retropharyngeal Space
    • Clinical - as above
    • Complications
      • Can track into danger space - entire length of posterior mediastinum
      • Mediastinitis and empyema
      • Can track into anterior and posterior regions of superior mediastinum
      • Aspiration pneumonia
  • Mx for para and retro
    • CT/MRI
    • IV abx
    • Source control
      • Remove causative tooth
    • Percutaneous drainage if confined to neck and no AW compromise
    • Surgical drainage if pus and going into chest
      • Cervical and thoracic approaches
    • SLT to clear the swallow prior to reinstituting diet
  • Prevertebral Space
    • Cause
      • Discitis/ostemyelitis - DM, immune comp, IVDU, EtOH
    • Clinical
      • As above
      • Plus cord compression - spinal epidural abscess
    • Mx
      • Same as above - dx, abx, drain if pus either USG or surgically
  • Other Considerations
    • Ludwig’s Angina
      • Bilateral infection of floor of mouth - submandibular, sublingual and submental spaces
      • Usually secondary to dental infection - mandibular molars
      • Polymicrobial cellulitis - aggressive and rapidly spreading
      • Can compromise AW

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